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Ted Schoch, a high school football official, has spent the past nine months preparing for the football season with the same vigor and passion as a young athlete. You may have seen him biking through Dalton or running drills at the sports facilities at Abington Heights High School.

Mr. Schoch has been recovering from a total knee replacement and met his goal of returning to work as a football official in this year's Dream Game. He is more excited than usual to officiate this football season. He, like many others, learned that it takes much more than traditional home exercises to get the most out of your knee replacement and get back in the game.

Total knee replacement is a very successful orthopedic surgery. More than 600,000 are performed in the United States each year, and more than 95 percent of patients are satisfied with the outcome one year later, according to the American Association of Orthopaedic Surgeons.

Pain relief with daily activities was the most important factor for most patients. Those dissatisfied are often younger and tend to have a long history of an active lifestyle. Many of these patients may have unrealistic goals and expectations; they would benefit from better preoperative counseling and longer, more aggressive rehabilitation. The program outlined here offers such an advanced fine-tuning rehab and full recovery for those hoping to hike, ski, play tennis or golf - and for those who seek better function in daily activities with their new knee.

Despite advances in knee joint implants - including more durable materials and improved simulation of natural joint movement - some patients continue to report dissatisfaction with postoperative function. Patients often complain about difficulty getting into or out of a car, descending stairs and bending to the floor. All of these activities have one thing in common: They require the ability to perform a partial squat.

Controlled lowering of body weight against gravity is not an easy task. The partial squat maneuver requires not only adequate mobility and strength at the hip, knee and ankle, but also equal weight bearing on both legs. The more advanced activity of descending stairs in a step-over-step manner requires even more effort as the leg muscles and joints must be strong and mobile enough to support the body's weight independently.

Studies show that even after two months of rehab following knee replacement surgery, patients continued to place more body weight on their nonoperative leg. This problem occurs for several reasons, including:

-âContinuation of a habit of walking in a manner to avoid knee pain before surgery.

-âContinuation of the "learned" compensation to avoid knee pain after surgery.

-âReflex muscle inhibition - when the body experiences pain, the muscles are inhibited to contract in order to avoid pain.

If not corrected, these three behaviors, whether acquired, learned or automatic, will continue for a long time after knee replacement surgery and prevent the best possible outcome for the patient.

To perform the functional squat maneuver necessary for daily activities, you must have adequate mobility at your hips, knees and ankles.

Functional squat

Hips must bend greater than 90 degrees, knees must bend at least to 90 degrees, and ankles must bend to about 12 to 15 degrees. Here, Mr. Schoch demonstrates a functional squat, with slight compensation in his right knee replacement due to lack of range of motion in his right hip and ankle.

In addition to adequate leg joint flexibility, a proper squat requires strength of several key muscles: gluteus (buttocks), hamstrings (back of the thigh), quadriceps (front of the thigh) and gastroc (calf).

During rehabilitation after knee replacement, even though knee function is paramount, failure to address hip/ankle mobility and strength may interfere with the restoration of important, daily tasks. For a replaced knee to perform optimally, the hip and ankle must be challenged with exercises similar to the following:

Calf stretching

Place hands on a wall and the uninvolved foot forward. Keep knees straight and the involved heel on the floor. Lean your body toward the wall. Hold 30 seconds; repeat three times.

Calf strengthening/ heel raise, both ankles

While standing, raise your heels up and down. (You may hold onto an object for stability.) Perform three sets of five repetitions. Advance to three sets of 10 to 15 reps.

Calf strengthening/ one ankle lowering

While standing, rise on your toes. Bend the uninvolved knee to raise your foot off the floor. With body weight on the involved leg, slowly lower the involved heel back to floor. (You may hold onto an object for stability.) Perform three sets of five reps. Advance to three sets of 10 to 15 reps.

PAUL J. MACKAREY, P.T., D.H.Sc., O.C.S., is a doctor in health sciences specializing in orthopedic and sports physical therapy. He is in private practice and is an associate professor of clinical medicine at Commonwealth Medical College. His column appears every Monday. Email: drpmackarey@msn.com.

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